1568460152 NPI number — DR. MARIE-JEANNE D MONDE-MATTHEWS MD

Table of content: DR. MARIE-JEANNE D MONDE-MATTHEWS MD (NPI 1568460152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568460152 NPI number — DR. MARIE-JEANNE D MONDE-MATTHEWS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONDE-MATTHEWS
Provider First Name:
MARIE-JEANNE
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568460152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 33321
Provider Second Line Business Mailing Address:
DRAWER 117
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48232-5321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-358-2410
Provider Business Mailing Address Fax Number:
248-358-2470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29255 NORTHWESTERN HWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-358-2410
Provider Business Practice Location Address Fax Number:
248-358-2470
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  4301056370 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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